This study has four aims: 1) Describe the pattern(s) of change in the degree of caregiver burden and depression after patients with dementia are permanently placed in a nursing home (NH). Comparisons will be made relative to caregivers of patients who were not placed in a NH over the same time period, caregivers of patients entering a nursing home following a hospital stay, and caregivers of patients admitted to NHs due to behavior or other factors without a hospital stay; 2) Determine which caregiver and patient factors prior to placement predict persistently high or increased levels of depression and burden after placement; 3) Develop and validate a prognostic index to identify caregivers at greatest risk of having persistently high burden and depression after relinquishing their at-home caregiver role; and 4) Integrate the prognostic index created in the large-scale secondary analyses as a targeting tool in the development and refinement of an evidence-based clinical intervention for dementia caregivers during institutionalization. The analyses will distinguish two types of nursing home placements: those occurring subsequent to a hospital episode and those resulting primarily from the patient's behavioral problems and not immediately preceded by a hospital stay. Prior studies have not made this distinction. Transferring care to a NH should bring relief of burden and depressive symptoms, but some caregivers may experience continued or even an onset of stress and depression due to feelings of guilt about the placement decision and their levels of involvement following institutionalization. It is expected that caregivers may experience fewer problems when the placement is the result of "medical" factors rather than patient problem behaviors or other care management factors. A better understanding of how these different types of placements influence caregiver outcomes will be useful in the translational objective of the proposed project: the design and development of a prognostic index that will assist in targeting clinical interventions to families adapting to nursing home placement. Data are from the Medicare Alzheimer's Disease Demonstration (MADDE) which operated from 1989-1994. This data set includes 8 geographic settings and 5,831 patient-caregiver dyads. Almost half of the care recipients entered nursing homes during the demonstration's study period. The sample size of the MADDE data set allows for the examination of multiple predictors of poor outcomes in caregivers after NH placement. It has a rich collection of caregiver information collected every 6 months and for up to 12 months after NH placement. This will be the largest study of caregiver burden and depression after NH placement and will yield valuable information in the development of a clinical intervention (the Enhanced Counseling and Support- Placement program) for dementia caregivers struggling to adjust to institutionalization. We intend to identify risk factors for persistent burden and depression among dementia caregivers following institutionalization. This information will inform the future development of a screening tool that could be administered to caregivers at the time their family member is transitioned into nursing home care. Effectively identifying and providing appropriate support/interventions to caregivers at highest risk of persistent burden and depression around the time of nursing home placement may reduce symptom severity, improve quality of life, and reduce other adverse health outcomes associated with caregiver burden and depression and heighten the impact of existing psychosocial interventions for family members of institutionalized older adults. [unreadable] [unreadable] [unreadable]